Any situation where the practice receives insurance money for filing a false claim, inflating a claim or billing for services not rendered, can be considered a crime. Even an accidental insurance mistake can lead to accusations of fraud and, guess what, such instances are more common than you think!. Fraud can take many different forms, but it most often involves illegitimate gain, deception, and intent. It is possible to land in trouble accidentally, but the intent behind fraud is what sets it apart from negligence. Therefore, your practice and its staff must be fully aware of both coding and the rules and regulations governing claim submissions. Always record and report your actions. However, ignorance is no excuse when it comes to fraud and it will not save you from going to prison or losing your license.
Here are some of the common billing mistakes that can lead to fraud:
Billing for services not performed or not completed
Although it looks self explanatory, there are more complexities to it. It is obvious that billing for a procedure that has not been carried out would be fraudulent. This makes it crucial to confirm the performance or completion of all services before making a claim. Also remember, basic extraction should not be upgraded to a more difficult surgical extraction, and the same goes for reporting a normal cleaning as a periodontal deep cleaning, which is more expensive. All this can lead to fraud, damaging the reputation of your practice and rupturing its overall functioning.
Waiving deductibles or copayments
When a copayment or deductible is waived, the practices will charge different rates than what the insurance provider believes should be charged. Practices are not permitted to waive their patients’ deductibles or copayments as set by insurance providers. Copayments and deductibles are the responsibility of the patient. Since it leads to false claims and excessive usage of services paid for by the insurance provider, waiving of deductibles or copayments is often regarded as fraud.
Altering dates of service
When a claim is presented with the wrong date of service, it can be considered a fraud. While initially appearing harmless, the date of service may have an impact on a patient’s ability to receive coverage if the treatment was rendered prior to the effective date of their insurance plan or before the conclusion of the plan’s waiting period. Make sure that the date of treatment coincides with appointment scheduling and clinical notations. It should also be related to patient eligibility and any applicable waiting period criteria.
Upcoding
Upcoding refers to the submission of insurance claims for procedures that were more difficult than what was actually performed. This is regarded as a major fraud. Utilizing codes for services the patient did not receive or for more complex treatments than the practitioner actually carried out can create a lot of mishaps at your practice. Insurance providers and regulatory bodies closely monitor upcoding as it can be used by practices as a means of evading insurance regulations and obtaining extra money from the payer. Practices must make sure that they only code for the actual services provided in order to prevent such dental billing issues.
Misrepresenting patient identities
Submitting claims for treatments using another patient’s data can be considered as another major fraud. Make sure you are filing claims for the actual patients. It is a fraud to treat one patient while intentionally or unintentionally filing the claim under the name of another in order to have the procedure covered. Also, misuse or disclosure of the patient’s specific dental care information in order to obtain payments from insurance providers is again a fraud. Ensure that patient data in your custody will always be safe and not be misused in any way.
Improper use of additional codes.
Always use the most appropriate code when submitting codes for treatments. Using multiple codes to indicate a service on a claim when one code is adequate is considered fraud. Do not break up a process into codes for local anesthetic, incisions, drainage, and sutures if there is already a code for a single service, such as an extraction, that covers the entire treatment. The process of breaking up codes is known as unbundling, which is not permitted.
Tips to prevent frauds
- Provide formal billing and coding training for your practice staff.
- Make sure your team is well informed of any changes to coding or insurance regulations.
- Submit claims that are fully accurate.
- Partner with a trustworthy dental billing partner to handle your claims
Why should you prevent frauds?
All involved in the dental sector can be harmed by acts of fraud. It can have an immediate impact on your practice in addition to raising the cost of insurance for both patients and employers. If your practice is found guilty of committing a fraud, you may have to pay fines, lose your professional license and access to networks, or perhaps you may even be sent to jail. Therefore, make sure that the claims that are submitted are accurate and are free of any mistakes that could end up landing you in jail.
